Slipping rib syndrome
Keywords: Slipping rib syndrome (+ Diagnosis / Therapy / Epidemiology / Rehabilitation / Examination / Symptoms / Characteristics / Clinical), clicking rib, painful rib syndrome, 12th rib syndrome, cyriax syndrome
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The slipping rib syndrome was first reported in 1919 by Cyriax. It is a condition, often misdiagnosed or underdiagnosed and can consequently cause months and even years of unresolved pain in the lower chest or upper abdomen, above the costal margin. Other features of the syndrome are a tender spot on the costal margin and reproduction of the pain on pressing the tender spot. The intensity of pain is related to mechanical conditions, such as bearning loads or coughing.
The slipping rib syndrome, far more common than realized, is also known by other names like clicking rib painful rib syndrome displaces ribs, interchondral subluxation, slipping rib cartilage syndrome, nerve nipping at the intercostal margin, Cyriax's syndrome, traumatic intercostal neuritis, rib-tip syndrome and 12th rib syndrome.
The condition will lead to a slipping rib under the superior adjacent rib. This because of the hypermobility of the anterior ends of the false rib costal cartilages (the 8th to 10th ribs, which are not directly insert into the sternum). The syndrome can be diagnosed by a clinical test (the hooking maneuver) and is often related to trauma (which can be neglected or forgotten), constrained posture and previous abdominal surgery.
Clinically Relevant Anatomy
The slipping rib syndrome is a condition in the area of the thorax. In the thorax, there are a lot of structures amongst others: a sternum, different kinds of ribs, muscles, nerves, arteries and veins.
There are 3 types of ribs:
• Ribs which are attached to the sternum by costosternal joints and ligaments (true ribs - 1-7th)
• Ribs which are connected to each other through a weaker cartilaginous or fibrous band (false ribs – 8-10th)
• Ribs which aren’t attached to the sternum or to each other (floating ribs – 11-12th)
Picture: The Thoracic Cage: Anterior view 
In most cases the slipping rib syndrome has an impact on the false ribs, mostly the 10th, occasionally the 8th or 9th rib . The rib cartilage (of the false ribs) can become hypermobile at different places and this can lead to cartilage tips and then to a subluxation of the rib. Al the ribs are attached to the thoracic vertebra.
Also a weakness of some ligaments of the rib can lead to a subluxation. Those ligaments can be: 
• Sternocostale ligament (rib-sternum)
• Costochondral ligament (rib-cartilage)
• Costovertebral ligament (rib-vertebral)
• Costotransversal ligament (rib-vertebral)
The subluxating rib can irritate several structures. This can result in the clinical presentation of the slipping rib syndrome. This structures can be:
• Intercostal muscles
• lower costal cartilage
• V./A. intercostal
• Intercostal nerves
Picture: intercostal muscles 
It affects 20% to 40% of the general population during their lifetime. The syndrome may occur at any age but it occurs infrequently in children and mostly middle-aged people are affected. The syndrome affects slightly more females than males.  People who play sports with higher risks for chest wall impacts (e.g. rugby, hockey, football players,…) have a higher probability to get the syndrome.
The slipping rib syndrome appears to be a fairly common and underdiagnosed chronic pain syndrome. The syndrome is caused by hypermobility of the rib cartilage of the false and floating ribs (mostly involved in this syndrome), this allows the costal cartilage tips to subluxate and irritating the intercostal nerves. This hypermobility is thought to be the primary cause of slipping rib syndrome.
The hypermobility of the ribs can be the result of thoracic or abdominal trauma (which can be neglected or forgotten) but this does not have to be. Others causes could be constrained postures and previous abdominal surgery.
The slipping rib syndrome is characterized by intense pain in the lower chest or upper abdominal area caused by trauma or dislocation of the 8th, 9th, and 10th ribs (false ribs). These ribs can be hypermobile because they do not attach to the sternum directly but they are attached to each other through a cartilaginous or fibrous band. Rib hypermobility can be caused by weakness of the rib-sternum (sternocostal), rib-cartilage (costochondral), and/or rib-vertebral (costovertebral/ costotransverse) ligaments.
Signs and symptoms are usually unilateral, however there are also cases where patients reported bilateral pain. 
The intense pain is usually described by patients as a constant monotonous pain that may last from several hours to many weeks. It also may cause a variety of somatic and visceral complaints.
The slippage or movement of the rib can lead to an irritation of the intercostal nerve, strain of the intercostal muscles, sprain of the lower costal cartilage or general inflammation in the affected area.
The impingement causes severe pain and a slipping sensation and is provoked by respiratory movements, bending, bearing loads, coughing and external influences e.g. palpation by the examiner.
Slipping rib syndrome is presented through the following characteristics: 
• pain in the lower chest or upper abdomen above the costal margin
• a tender spot on the costal margin
• reproduction of the pain by pressing the tender spot.
The differential diagnosis of slipping rib syndrome includes:
• Gastric ulcer
• Hepatosplenic abnormalities
• Stress fracture
• Inflammation of the chondral cartilage
• Pleuritic chest pain
• Herpes zoster
• Aortic aneurysm
• Tietze syndrome (syndrome typically affects one joint and is associated with swelling)
• Costochondritis (may affect numerous costochondral joints with no swelling)
• Muscle tears
• Abdominal diseases
The slipping rib syndrome can be diagnosed by sonography and physical examination. It is often overlooked because of the lack of available paraclinical procedures and because CT scans has almost replaced a thorough clinical examinations for patients with flank pain.
Interchondral joints can be precisely depicted with sonography and sequential scanning allows an accurate count of them. On the other hand, high-resolution sonography of the thoracic wall shows accurately the luxation of the cartilaginous rib.
Sonography is also used to exclude other causes of thoracic pain such as rib fractures, Tietze syndrome, abscesses, metastases, muscle tears, pleuritis, and abdominal diseases.
The hooking maneuver, first described in 1977, is a relatively simple clinical test which can be used to diagnose the syndrome. For more information see examination.
Generally radiologic imaging is not useful in the diagnosis of slipping rib syndrome, but it can be used to exclude the other conditions in the differential diagnosis.
• Evaluation of the patient
To look for an association between certain movements or postures and pain intensity. 
• Determine if the patient has experienced recent trauma (although not always present). The physiotherapist can reproduce chest pain by palpation of the ribs and chest wall. 
• Hooking maneuver
Reproduce the symptoms (see characteristics) with the hooking maneuver. This is a relatively simple clinical test where the clinician places his or her fingers under the lower costal margin and pulls the hand in an anterior direction. Pain or clicking indicates a positive test.
• Valsalva maneuver
The physiotherapist can look for rib restriction by observing a lack of symmetry of the posterior chest wall movements on deep breathing. During the Valsalva maneuver, it is possible to palpate the slipping of the rib as the abdominal muscles contract.  
The slipping rib syndrome is often misdiagnosed or underdiagnosed. The physiotherapist looks for an association between certain movements or postures and pain intensity (signs and symptoms), determines if the patient has experienced recent trauma (not always present), constrained posture, or previous abdominal surgery and reproduces the symptoms (eg, pain, clicking).
Picture: Hook maneuver 
1. Signs and symptoms
Classically, the pain occurs in the upper abdomen or lower chest, above the costal margin. Severe, sharp pain is felt in the anterior costal margin and abdominal wall. A painful click is sometimes felt over the tip of the involved costal cartilage with certain movements. The involved costal cartilage is tender and moves more freely than normal.
See clinical presentation
2. Physical examination
There are two tests for investigating Slipping rib syndrome: the Hook maneuver and Valsalva maneuver. Palpation can reproduce chest pain when the patient has the slipping rib syndrome. The diagnosis of this disease is one of exclusion.
The hook maneuver
This test was described by Heinz and Zavala. In this test the patient lies on his unaffected side, while the therapist hooks his fingers under the lower costal margin and pulls anteriorly (anterior stretching). A positive test reproduces the patient’s pain and can cause a click. The condition is always unilateral, performing the maneuver on the contralateral side will serve as a control.
The physiotherapist can look for rib restriction by observing a lack of symmetry of the posterior chest wall movements on deep breathing. During the Valsalva maneuver, it is possible to palpate the slipping of the rib as the abdominal muscles contract.
At physical examination, the most common finding in a case of SRS is tenderness above the costal margin. The physiotherapist can reproduce chest pain by palpation. This is the most important characteristic to diagnose CWS (this is not pathognomonic).
The treatment of slipping rib syndrome is possible by a multidisciplinary approach. The multidisciplinary approach consists of surgeons, pain clinic specialists, radiologists, and psychiatrists. There are various methods of treatment, which may be determined by the patient. Strapping, local infiltration of lidocaine, intercostal nerve block or surgical excision of the affected rib cartilages is reserved for refractory cases.
Medical management can include:
1. Recognition of the condition and reassurance.
The patient can be taught to avoid movements and positions that provoke the pain. (LoE 3A)
2. Local anaesthetic (intercostal) nerve blocks
Nerve blocks involves the injection of an anesthetic, a corticosteroid and other agents onto or near a nerve, usually for pain relief or anesthesia. It usually lasts hours or days. The procedure can easily be repeated if required. The immediate relief afforded by this procedure is often sufficient to reassure the patient of the ‘musculo-skeletal’ pain diagnosis. Local anaesthetic nerve blocks was proven useful in some cases.
a. Local anaesthetic and long-acting steroid (depomedrone 40 mg in 5 mL 0.25–0.5% bupivacaine) (LoE 3A)
b. supplementation of corticosteroids can give varying amounts of relief (LoE 3A)
NSAID might be value. (LoE 5)
• Wiring of a ‘slipping rib’
Wiring of a ‘slipping rib’ through the costo-chondral junction has been described but is rarely required. (LoE 5)
• Rib excision
At failure of this general management, removal of the anterior end of the rib and costal cartilage may be performed. This has many reports of successful outcomes, reported in the literature (LoE 4). They make an incision along the costal margin (directly over the point of maximum tenderness). The eighth, ninth or tenth ribs are almost always involved. You must take care to inspect all three ribs and perform appropriate resection.
• Pulse radiofrequency treatment of dorsal root ganglion
Percutaneous dorsal root ganglion radiofrequency thermo-coagulation performed under local anaesthetic with X-ray screening (LoE 1B)
Physical Therapy Management
Specific for slipping rib syndrome
- Recognition of the condition and reassurance. The patient can be taught to avoid movements and positions that provoke the pain without creating asymmetric over charge in other regions of the body. (LoE 3A)
- Reassurance of the benign nature of the disease combined with explanation and advice concerning postural avoidance  (LoE: 3A)
- The therapeutic attitude is far from consolidated. Most authors advise treatment depending on the intensity of pain. In moderate pain, we recommend wearing an elastic bandage around the thorax for 1 to 2 weeks, associated with pain treatment and psychological support (LoE: 4) 
- Using heat and <a _fcknotitle="true" href="Ultrasound">Ultrasound</a> to the affected rib and <a _fcknotitle="true" href="NSAID">NSAID</a>s might be of value (LoE 5) 
There is a lack of articles that describe the physical treatment of slipping rib syndrome. For that reason we used some other conditions that have a connection to this disease.
-<a _fcknotitle="true" href="Manual therapy">Manual therapy</a>: manipulation of the costovertebral joint can help manage the pain
- Local anaesthetic nerve blocks was proven useful in some cases (a supplementation of corticosteroids can be helpful)
- At failure of this general management, removal of the anterior end of the rib and costal cartilage may be performed. This has many reports of successful outcomes, reported in the literature.
Chest Wall Syndrome
We found an article that gives some guidance of moderate evidence (LoE 3A) of the physical treatment of Chest Wall Syndrome (Generic Term of Slipping Rib Syndrome). This article suggests as part of the treatment to give the patient a good explanation of the mechanism of the disease and proposes a logical postural avoidance. With this approach the patient is limited in his movements and may better tolerate the discomfort. Strapping the ribs has provided limited relief in a few cases. 
Manipulative techniques may treat this syndrome, for example the manipulation of the costvertebral joint in combination with anaesthetic nerve blok and/or corticosteroids injections.
Treatment of a Subluxation Rib
A subluxating rib is a symptom of slipping rib syndrome, that’s the reason why we can inspire us on this article with low evidence (LoE 5)
- Muscle training of the small local muscles such as the <a _fcknotitle="true" href="Multifidi">Multifidi</a>, rotatores and levator costalis in an attempt to stabilize the sprained CV and CTr joints. (LoE 5) Par example: <a _fcknotitle="true" href="Core stability">Core stability</a> training.
- Rib mobilization with movement (MWM) as proposed by Brian Mulligan. The range of motion and pain level are evaluated. A cranial glide is applied over the lateral aspect of the rib above the painful region. While sustaining this rib elevation/unloading, the patient is asked to rotate again while ROM and pain are once again evaluated. If there is no change, the technique is repeated on a rib above or below. If MWM on a rib at a specific levels is found to reduce or eliminate the pain, it is repeated 10 times. 
Picture: rib mwm 
- A home program of self MWM may be provided. Instruction: “lift the rib up with the web space of one hand and actively rotate towards the painful direction, repeat as often as necessary”. The goal is to move the irritated CV joint short of pain as often as possible to reduce both the protective muscle spasm and the local inflammation.
Picture: rib self-mwm 
- Taping of rib can possibly provide some temporary relief. To decide on the location and direction of taping, apply a manual superior compression force through the postero-lateral aspect of the rib cage. Now ask the patient to take in a deep breath or rotate. If the patient notes a significant improvement in symptoms, then apply the tape at that level.
Picture: rib staping step #1 
This condition has also as purpose restoring normal thoracic and rib joint movement.
- Diversified manipulation (high-velocity, low-amplitude [HVLA]) of posterior joints, and manipulation of anterior joints by means of an activator helps restoring the normal thoracic and rib joint movement.  (LoE 4)
Clinical Bottom Line
The slipping rib syndrome will lead to a slipping rib under the superior adjacent rib. The impingement can cause severe constant monotonous pain and a slipping sensation provoked by several movements. It can also lead to an irritation of the intercostal nerve or problems to structures in that area. This because of the hypermobility of the anterior ends of the false rib costal cartilages often related to trauma. It can be diagnosed by sonography and physical examination.
Management of the slipping rib is most of the time a medical approach. First they use local pain medication but if that’s not working they can use surgical methods. There is not a lot of evidence of the physical management for this condition is scarce, only patient education, using heat and ultrasound using elastic bandage for 1 to 2 weeks associated with pain treatment and psychological support. There are some advises for other conditions that we can use for the treatment of the slipping rib syndrome.
Recent Related Research (from Pubmed)
1.Udermann B.E., et al., Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report, J Athl Train, 2005 (LoE 3B)
2. Scott E.M., et al., Painful rib syndrome--a review of 76 cases, Gut, 1993 July (LoE 3A)
3. Heinz G.J., et al., Zavala DC, Slipping rib syndrome, JAMA1977; 237(8): 794-5 (LoE 5)
4. DeLisi N., et al., Slipping rib syndrome: ’there’s an easier way’, Geriatrics, 1995 (LoE 5)
5. Gregory P.L., BISWAS A.C., Batt M.E., Musculoskeletal problems of the chest wall in athletes, Sports Med., 2002. (LoE 3A)
6. Cyriax E, et al., On various conditions that may simulate the referred pains of visceral disease and a consideration of these from the point of view of cause and effect, Practitioner, 1919 (LoE 5)
7. Kocis K.C., et al., Chest pain in pediatrics, Pedriatic Cardiology, University of Southern California, 1999 (LoE 5)
8. Bass J., et al., Slipping Rib Syndrome, Journal of the National Medical Association, 1979 (LoE 4)
9. Adel G., et al., Musculoskeletal chest wall pain, Can Med Assoc J, 1985, (LoE 5)
10. Migliore M., et al., Flank pain caused by slipping rib syndrome, The Lancet, 2014 (LoE 4)
11. Machin D.G., et al., Twelfth rib syndrome: a differential diagnosis of loin pain, British Medical Journal, 1983 (LoE 4)
12. Meuwly J. et al., Slipping Rib Syndrome A Place for Sonography in the Diagnosis of a Frequently Overlooked Cause of Abdominal or Low Thoracic Pain, Journal of ultrasound in medicine, 2002. (LoE 4)
13. Paik S.H., et al., High-Resolution Sonography of the Rib : Can fracture and Metastasis Be Differentiated?, American Journal of Roentgenology, 2005 (LoE 2B)
14. Malghem J., et al., Costal Cartilage Fractures as Revealed on CT and Sonography, American Journal of Roentgenology, 2001 (LoE 2B)
15. Barki J., et al., Painful rib syndrome (or Cyriax syndrome). Study of 100 patients, Europe PMC, 1996 (LoE 3A)
16. Keoghane S.R., Twelfth rib syndrome: a forgotten cause of flank pain, BJUI International, 2008 (LoE 5)
17. 17. Ronga A. et al., Development and validation of a clinical prediction rule for chest wall syndrome in primary care. BiomedCentral, 2012. (LoE 2B)
18. 18. N. Gonzales Temprano, Slipping rib syndrome. An aggressive but effective treatment. Anales del Sistema sanitario de Navarra, 2014. (LoE 4)
19. Chan P. et al., Assessing the effectiveness of ‘pulse radiofrequency treatment of dorsal root ganglion’ in patients with chronic lumbar radicular pain: study protocol for a randomized control trial. BiomedCentral, 2012.(LoE 1B)
21. Nilsson S, Scheike M, Engblom D et al. Chest pain and ischaemic heart disease in primary care. Br J Gen Pract 2003; 53: 378–82
22. Verdon F, Herzig L, Burnand B et al. Chest pain in daily practice: occurrence, causes and management. Swiss Med Wkly 2008;
23. Cranfield K.A.W. et al., The twelfth rib syndrome, Journal of Pain and Symptom Management, 1997. (LoE 3B)
24. Van Delft E.A.K., et al., The Slipping Rib Syndrome: A case report, International Journal of Surgery Case Reports, 2016. (LoE 4)
25. Verdon F. et al., Chest wall syndrome among primary care patients: a cohort study, BMC Family Practice. (LoE 2B)
26. Veeram S.R., Singh H.R. et al., Chest Pain in Children and Adolescents, Pediatrics in Review, 2013. (LoE 4)
27. Mooney D.P., Shorter N.A., Slipping rib syndrome in childhood, Journeys of Pediatric Surgery, 1997. (LoE 3B)
28. Kumar R. et al., The painful rib syndrome, Indian Journal of Anaesthesia, 2013. (LoE 4)
29. Hudes, K, Low-tech rehabilitation and management of a 64 year old male patient with acute idiopathic onset of costochondritis, J Can Chiropr Assoc. 2008 Dec;52(4):224-8. (LoE 4)
30. Bahram, J, Ribs don’t sublux, ribs don’t “go out” … so what’s going on?, Advanced
Physical Therapy Education Institute, 2015 (LoE: 4)
31. Gijsbers, E, Clinical presentation and chiropractic treatment of Tietze syndrome: A 34-year-old female with left-sided chest pain, J Chiropr Med., 2011, 10(1),60-63 (LoE: 4)
32. Roche, N, Syndrome de la cöte glissante ou syndrome de Cyriax, La Presse Médicale, 2010,10, 024 (LoE 4)